Provider Demographics
NPI:1689659708
Name:GEORGIADIS, CONSTANTINE ALEXANDER (DO)
Entity Type:Individual
Prefix:DR
First Name:CONSTANTINE
Middle Name:ALEXANDER
Last Name:GEORGIADIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Mailing Address - Street 1:2675 WINKLER AVE
Mailing Address - Street 2:FL 2
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:407-200-2300
Mailing Address - Fax:407-200-1365
Practice Address - Street 1:3000 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-8616
Practice Address - Country:US
Practice Address - Phone:941-406-9022
Practice Address - Fax:941-883-4101
Is Sole Proprietor?:No
Enumeration Date:2005-12-12
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CO37204207Q00000X
FLOS12005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL14PK5OtherFL BC
FL14PK5OtherFL BC
H51510Medicare UPIN